Dr Raymond Yeow

Advanced Medical Practice

Windsor

NSW 2756

16.03.2024

Re: Hayley McGregor (DOB: 26.11.2003) Review at close of referral

Dear Dr Yeow,

Thank you for re-referring Hayley McGregor in August for a Wentworth Healthcare’s PTS plan for depression, anxiety and PTSD.

Hayley had her first appointment on the 14th of August, 2023. She engaged well and attended fortnightly to monthly appointments with a total of five. Unfortunately, she did not attend scheduled consultations in December and I have been unable to contact her since. I have also tried to contact her mother (NOK) and left messages for both, however they have not returned my calls. Hence, I have closed the referral due to loss of contact. At the time of my last session with Hayley, I had no reason to be concerned about her safety.

Current Presentation

Since the close of her previous referral, Hayley had been going well, going to the gym and moving forward with her life. Unfortunately, she saw the perpetrator of her previous sexual assault, and that triggered a relapse in mental health. She stated that since then she had had “waves of paranoia and thoughts that he would harm me.” She reported struggling with thoughts to self-harm and had increased suicidal ideation. She had been able to manage the thoughts and not act on them at that time.

Hayley expressed general concerns about her mental health, including difficulty sitting still, mood lability and impulsivity. She reported that her MGM and PGM had bipolar disorder and she questioned if she might have the same, or ADHD. She reported episodes of getting very angry and abusive, or crying and having panic attacks.

At the time of her initial presentation under this plan, Hayley reported being recently diagnosed with PCOS. She had had surgery for abdominal pain/appendectomy, however had found an ovarian cyst and was subsequently found to have more than twenty cysts in her right ovary. She was also struggling with ongoing issues with chronic leg pain from a workplace injury, and had planned to have nerve blockers to manage the pain. Ongoing issues with compensation claim were a source of ongoing stress.

Hayley reported challenges with eating – either over eating or starving herself. She was isolating herself, but aware of pushing through that to manage her life, no longer succumbing to the low mood and staying in bed like she would have in the past. She wanted to start healing and move forward to a future that included marriage and children. Her social life had also improved and she was taking time for self-care. She had new friends and was enjoying an active social life. She had upcoming part-time work she was looking forward to and was studying to get her real estate license.

26.11.21: K10 score: 37/50

21.01.22: K10 score: 22/50

22.04.22: K10 score: 45/50

15.07.22: K10 score: 14/50

14.08.2023: K10 score: 42/50

See previous correspondence for comprehensive mental health assessment and more information.

Update

On the 28th of August, 2023, Hayley contacted me with increased thoughts to self-harm. We discussed safety over the phone and whilst she was able to give assurance of not acting on the thoughts, she wanted to seek additional support and self-presented to Nepean Hospital TAC. She subsequently saw Dr Naaz, psychiatrist in Windsor, and was diagnosed with bipolar affective disorder; borderline personality disorder, alcohol misuse disorder and perfectionism/anxiety disorder. She was prescribed Olanzapine 5mg in TAC, which was then changed to Seroquel 150mg nocte by Dr Naaz.

Hayley and her mum attended a joint consultation at this time and I was able to elicit more information about her earlier years and developmental history (see below).

In September, 2023, Hayley broke up with her partner of 4 years. This was a difficult time for Hayley, however she managed the emotions relatively well. She was able to see the positives of their relationship, what she had learned and what she wanted her next relationship to look like. We explored alcohol use and impulsivity and ways to detect early warning signs of relapse and create an action plan should this occur.

At the time of her last consultation on the 16th of October, 2023, Hayley reported grief coming up about the breakup and how she was coping with that. She had realised about past unhelpful behaviours and wanting to move forward with healthier boundaries in relationships. Her main goals at this time were:

To start my life

To be in a healthy relationship

To be the main character in my life

To go back to the things I used to enjoy – painting, church

Consider art school

Hayley did not attend the next few scheduled consultations in December. I contacted her and her mother by phone in December and February 2024 and left messages to contact me, however they did not return the calls. I did not have any concerns about her safety at that time, as Hayley was coping well with distress and had plans for her future.

Family mental health history:

MGM and PGM bipolar disorder

Father: narcissistic personality disorder

PGF and PGM: AOD

MGM: alcohol and bipolar

Developmental history:

Born and low birth sounds humidicrib

Easy baby; liked routines for sleep; didn’t self soothe.

Cranial dysplasia

Umbilical hernia

Milestones on time

Academically low in early years; easily distracted

Friendship issues in primary school.

Year 4: changed primary schools

Year 9: Bede Polding

Yr 10: Colo High

13 – 14: noticed changes in mood – low and DSH.

16: used to stay in bed all day and dropped out of school.

From 2014: Mother worked a lot and father more home based, however “emotionally unavailable and we clashed.”

We were able to explore ways for Hayley to communicate with her mother when not going so well.

MSE

Unable to assess as no contact recently.

Formulation from initial consult

21 year old Caucasian female living at home with her parents, recently diagnosed with bipolar disorder, BPD, anxiety and alcohol misuse disorder, presenting with deterioration in mental health, including increased thoughts to DSH and suicidal ideation, triggered by contact with perpetrator of sexual assault and relationship breakup. Currently lost to contact.

Impression – consider:

Complex PTSD

Plan

Referral has been closed due to loss of contact.

Should Hayley need psychological support at another time, I’d be happy to see her.

Regards,

Michelle Hookham